Comparative analysis of direct routine left ventricular guidewire pacing and right ventricular pacing: A faster and safer approach to TAVR

Traditional right ventricular (RV) pacing during transcatheter aortic valve replacement (TAVR) carries risks such as vascular complications and pericardial effusion. Alternative pacing strategies, such as routine left ventricular (LV) guidewire pacing, may offer improved outcomes by simplifying procedures and enhancing safety.

This study aimed to evaluate the efficacy and safety of routine LV guidewire pacing compared to RV pacing in patients undergoing TAVR.

A total of 635 patients undergoing TAVR were included, with 436 in the LV pacing group and 199 in the RV pacing group. Outcomes were assessed at 30 days, focusing on all-cause and cardiovascular mortality, composite safety outcomes, and procedure-related complications. Subgroup analyses examined the impact of different RV pacing lead types on outcomes.

LV pacing demonstrated lower all-cause mortality (5.1 vs. 11.4%) and cardiovascular mortality (4.6 vs. 9.4%) at 30 days compared to RV pacing. However, adjusted analyses showed no significant differences (aHR, 1.69; 95% CI, 0.88-3.26; P = 0.112). Composite safety outcomes (pericardial, vascular complications, and bleeding) significantly favored LV pacing (aHR, 2.43; 95% CI, 1.44-4.12; P <0.001), with fewer pericardial complications (aHR, 7.15; 95% CI, 2.52-20.28; P <0.001) and inguinal hematomas (aHR, 2.01; 95% CI, 1.02-3.97; P = 0.042). Subgroup analysis showed that balloon-tipped RV leads produced outcomes comparable to LV pacing, while conventional RV leads were associated with higher mortality risks (aHR, 2.86; 95% CI, 1.41-5.78; P = 0.003).

Routine LV pacing offers significant advantages over RV pacing, including reduced complication rates, shorter procedure times, and greater efficiency. These findings support its potential as a safer and more effective standard pacing strategy in TAVR, pending further validation through randomized trials.